Here is what EMS agencies need to know to maintain training requirements and compliance with the OSHA bloodborne pathogens standard

A study from the National Institute for Occupational Safety and Health reviews safety measures medics can take

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The federal Occupational Health and Safety Administration, or ‘OSHA’ was created by Congress under the Department of Labor in 1970 to better protect workers by assuring safe and healthy working conditions.

The Bloodborne Pathogens (BBP) standard, found in the Code of Federal Regulations (29 CFR1910.1030), took effect in March 1992 to reduce what then amounted to more than 200 deaths and 9,000 bloodborne infections each year. The standard was amended by the Needlestick Safety and Prevention Act of 2000 (Pub. L. 106-430) to address a rising incidence of accidental sharps injuries. The Bloodborne Pathogens standard remains the most frequently accessed standard on the OSHA web site[1] which, in allb likelihood, suggests significant need for information and clarification about the standard.

BBP training requirement’s

The BBP standard covers any work-related (including volunteer labor) exposures to blood or other potentially infectious materials as defined in the standard.

Generally, the standard requires employers to develop an exposure control plan and update it annually, implement the use of standard precautions as well as engineering controls and practices to protect workers, supply personal protective equipment, make hepatitis B vaccinations available, provide post-exposure evaluation and follow-up, use labels and signs to indicate hazards, provide information and training to workers, and maintain medical and training records. This article focuses specifically on the training requirements.

Digging through the standard, you will find training mentioned in several places: Bloodborne Pathogens 1910.1030(g)(2)(i); (ii)(A) through (C); (iii) through (vii)(A) through (N); (viii) and (ix)(A) through (C).

BBP training must be provided at no cost and during the employees’ working hours. Training also needs to be in the worker’s own language and at a level appropriate to the worker’s educational and literacy level.

There are three types of training: initial, additional and annual.

Initial training is done on hire or when a volunteer starts with an organization, and must be completed before the worker begins work in any role where they have a risk of exposure.

Additional training is provided when assigned tasks or risks of exposure change, or when new safety procedures or equipment are put in place.

Annual training is done within one year of the previous training.

Initial training is specifically detailed in the BBP standard to include:

Access to a copy of the 1910.1030 standard and an explanation of its contents

A general explanation of bloodborne diseases and their symptoms

Information on modes of transmission of bloodborne pathogens

Review of the employer’s exposure control plan and information about where the worker can obtain a copy of the written plan

Description of methods for recognizing tasks that involve potential for exposure to BBP and OPIM

Explanation of methods to prevent or reduce exposures (engineering controls, work practices, PPE) including limitation of these methods

Appropriate actions to take in an emergency involving blood or OPIM and who to contact to determine if an exposure has occurred

Information on procedures to follow after an actual BBP exposure, including how to report the incident and what medical follow-up will be made available

Details on post exposure evaluation and follow-up

Explanation of any signs and labels or color coding used by the employer to comply with the BBP standard

An opportunity for interactive questions and answers with the person conducting the training session

The four most common questions about the initial training are:

What diseases need to be covered?

Who is qualified to conduct the training?

What exactly does OSHA mean by interactive Q&A?

Are there specific time requirements?

When in doubt, ask OSHA

None of these are explicitly described in the standard itself, and this results in considerable confusion among EMS services and other employers. Fueling this confusion are self-proclaimed authorities who offer interpretations that may not be consistent with OHSA’s intentions.

Questions about any standard should be directed to the author of the standard itself. OSHA accepts questions, makes careful interpretations of their standards, and posts these interpretations online for anyone to read. Called “Standard Interpretations,” these answers to queries cover the most common and sometimes inane sort of questions others have asked.[2]

Under the bloodborne pathogens standard 1910.1030, there are currently 278 Standard Interpretations. Perusing these can be somewhat overwhelming but using key words in your web browser will usually lead to the answers you need.

For example, the four most common questions above all involve training requirements. Using the “find on this page” feature to look for the word, ‘train’ would readily highlight applicable correspondence.

OSHA also enforces their standards; failure to comply can result in fines. To assure consistency among inspectors and assist employers in understanding what is expected, OSHA issues Compliance Directives.

These are also available online; for the bloodborne pathogens standard, there are currently two.[3] The first is OSHA’s own exposure control plan for its employees (who OSHA expects are not reasonably anticipated to have exposures to BBP). The second is specific instructions for OSHA staff on how inspections are to be done. Included are examples of engineering controls evaluation forms and a model exposure control plan.[4].

OSHA’s definition

OSHA defines bloodborne pathogens in their standard as any “pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).”

The fact that a worker can be reasonably anticipated to have exposure to BBP means that all of the potential diseases associated with blood and body fluids need to be covered in the initial training.

Conveniently, the Ryan White Law of 2009 required the Secretary of Health and Human Services (HHS) to publish a list of potentially life-threatening infectious diseases.[5] This requires health care facility notification to emergency response employees (EREs) when they diagnose a patient. The HHS list happens to be broken down into categories of disease transmission, one of which is “contact or body fluid exposures.” These are the diseases, at minimum that need to be covered in initial BBP training.

BBP training resources

There are many resources for training materials, particularly materials suitable for initial training. EMS textbook publishers and OSHA compliance publishers, as well as publishers of first aid and CPR textbooks, provide a variety of resources useful for delivering BBP training.

Additional training, conducted when assigned tasks or risks of exposure change, or more likely when new safety procedures or equipment are rolled out, is often less difficult to obtain training materials for. Annual training, however, can be a challenge.

OSHA has repeatedly indicated that the primary purpose of annual training is to provide workers with an update of changes.[2] Unfortunately, many employers are under the impression that annual training is designed to review the initial training. While OSHA agrees that this is worthy of consideration, it is not the intended objective.

That means that annual BBP training should be new and different every year. Training aids that reflect these updates in science, with opportunity to customize with employer policies and procedures, are not widely available. One source is Infection Control Emerging Concepts operated by Katherine West, an infection control consultant well known in the EMS and fire service communities.

Who is qualified to conduct BBP training?

This leads to the age-old question of who is qualified to conduct BBP training. In their guidance for inspectors, OSHA defines the qualifications needed for a trainer to include any person who is, “knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace.”

The trainer also needs to be familiar with how the elements of the training program relate to the particular workplace. There is no requirement that the trainer be a licensed or certified health care provider. Unless OSHA believes the training program is deficient, they typically would not investigate the qualifications of the trainer.

When needed, OSHA would consider the trainer’s completion of specialized courses, degree programs, or work experience. They would also consider whether the trainer has received specialized training. There is no magical “certification” that would qualify anyone to be a qualified BBP trainer.

Training is largely performance based, that is, predicated on whether the trainer and the training materials accomplish the goal of educating workers about the required training elements of the BBP standard.

Increasingly, online and distributive learning programs are being used to deliver education and training to workers. While programs delivered by video, computer, or other means assure consistency, they can present challenges meeting the OSHA requirement that they provide the opportunity for interactive questions and answers with the person conducting the training session. This has been the source of numerous inquiries,[2] and will probably generate more questions and answers as learning technologies continue to evolve.

To date, OSHA has made it clear that the trainer does not need to be physically present in the classroom during the training. However, workers must have direct access to the trainer to ask questions at the time of the training. OSHA has clarified that a “telephone hotline” and direct video conferencing link is acceptable. They have also clarified that leaving a voice mail message or sending an email with questions is not acceptable.

Clearly, training must include ability for attendees to have real-time access to a trainer. OSHA has also indicated that a potential weakness of computer-based and video training may be that it lacks an opportunity for workers to practice use of safety equipment, including PPE. Employers should integrate opportunity for hands-on practice with each BBP training session.

No minimum time requirements

The last of the commonly asked questions about BBP training is whether OSHA has defined a required number of hours or minimum time needed for initial, additional or annual BBP training.

The answer to this, after searching all of the OSHA references,[1-3] is an unequivocal “no.” Training under the BBP standard is entirely performance based.

This means that the number of hours needed for any training equals the time necessary to accomplish the objectives of that training. It will vary depending on the experience and educational background of the workers, and the details of the employer’s exposure control plan.

An EMS agency, for example, would likely find that the number of hours needed for initial training varies between EMTs paramedics, and physicians based on the knowledge and experience of each. Annual training will vary from year to year, depending on changes in infectious organisms, medical science, and safety equipment. Some years, annual training might be incredibly brief. There is no possible way that OSHA or anyone else could define specific hour requirements to meet a performance based standard.

The bottom line to bloodborne pathogen training is that OSHA has readily accessible and specific objectives for initial, additional and annual training. Every emergency response organization needs a trainer who is familiar with infection control science, able to stay up to date on changes, and aware of how those changes affect the organization.

Canned or commercial training programs can be helpful, but cannot replace a qualified trainer. BBP training is performance-based and will look different in every organization, depending on the needs, experience, education and background of the workers.

Mike McEvoy, PhD, NRP, RN, CCRN is the EMS Coordinator for Saratoga County, New York and a paramedic supervisor with Clifton Park & Halfmoon Ambulance. He is a nurse clinician in cardiothoracic surgical intensive care at Albany Medical Center where he also Chairs the Resuscitation Committee and teaches critical care medicine. He is a lead author of the “Critical Care Transport” textbook and Informed® Emergency & Critical Care guides published by Jones & Bartlett Learning. Mike is a frequent contributor to EMS1.com and a popular speaker at EMS, Fire, and medical conferences worldwide.Contact Mike at mike.mcevoy@ems1.com.

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